Evaluating the perceptions of a required didactic Mental Health First Aid training course among first-year pharmacy students.

BACKGROUND AND PURPOSE: Mental Health First Aid (MHFA) training was designed to help participants identify mental health challenges and provide support to those in need. The objective of this study was to evaluate the perceptions of a required first-year didactic MHFA course and to determine if MHFA reduces stigma and increases confidence in first-year pharmacy students' abilities to offer help to those experiencing a mental health challenge or a crisis. EDUCATIONAL ACTIVITY AND SETTING: Participants were first-year doctor of pharmacy students at a single site in the United States. Methods include the utilization of a survey-based study among a single pharmacy program. Students enrolled in this required MHFA training were asked to voluntarily complete pre- and post-training surveys. FINDINGS: A total of 69 first-year pharmacy students participated in the MHFA training. Results demonstrated that students agreed with being able to identify stigmatizing words associated with mental health disorders and that they will work to reduce or avoid using words that can be perceived as stigmatizing related to mental health (P < .001). Students reported increased confidence in their ability to start a conversation with someone who may need mental health help compared to their confidence level before the training (P < .001). SUMMARY: Completing MHFA training during the early phases of didactic education can help reduce stigma and increase confidence in abilities to help those experiencing a mental health challenge. Programs should consider implementing MHFA or similar training early in the didactic curriculum.

Impact of pharmacists on outcomes for patients with psychiatric or neurologic disorders.

INTRODUCTION: Psychiatric and neurologic illnesses are highly prevalent and are often suboptimally treated. A 2015 review highlighted the value of psychiatric pharmacists in improving medication-related outcomes. There is a need to describe areas of expansion and strengthened evidence regarding pharmacist practice and patient care impact in psychiatric and neurologic settings since 2015. METHODS: A systematic search of literature published from January 2014 to June 2019 was conducted. Publications describing patient-level outcome results associated with pharmacist provision of care in a psychiatric/neurologic setting and/or in relation to central nervous system (CNS) medications were included. RESULTS: A total of 64 publications were included. There was significant heterogeneity of published study methods and data, prohibiting meta-analysis. Pharmacists practicing across a wide variety of health care settings with focus on CNS medication management significantly improved patient-level outcomes, such as medication adherence, disease control, and avoidance of hospitalization. The most common practice approach associated with significant improvement in patient-level outcomes was incorporation of psychiatric pharmacist input into the interprofessional health care team. DISCUSSION: Pharmacists who focus on psychiatric and neurologic disease improve outcomes for patients with these conditions. This is important in the current health care environment as most patients with psychiatric or neurologic conditions continue to have unmet needs. Additional studies designed to measure pharmacists' impact on patient-level outcomes are encouraged to strengthen these findings.

Community pharmacists and mental illness: a survey of service provision, stigma, attitudes and beliefs.

Background Half of Americans experience mental illness during their lifetime. Significant opportunity exists for community pharmacists to deliver services to these patients; however, personal and practice-related barriers may prevent full engagement. Objective To assess the demographics, practice characteristics, service provision, stigma, attitudes and beliefs of a national sample of community pharmacists towards individuals with mental illness. Setting National random sample of 3008 community pharmacists in the USA. Method 101-item cross-sectional mailed survey questionnaire on: (1) demographics, (2) knowledge and practice characteristics, (3) provision of clinical pharmacy services, and (4) comparative opinions. Main outcome measure Scaled measures of service provision (comfort, confidence, willingness and interest) and comparative opinions (stigma, attitudes and beliefs) of mental illness, four linear regression models to predict service provision. Results A total of 239 responses were received (response rate 7.95%). Across pharmacy services, ratings for willingness/interest were higher than those for comfort/confidence. Pharmacists who reported providing medication therapy management (MTM) services for patients reported higher comfort (18.36 vs. 17.46, p < 0.05), confidence (17.73 vs. 16.01, p < 0.05), willingness (20.0 vs. 18.62, p < 0.05) and interest (19.13 vs. 17.66, p < 0.05). Pharmacists with personal experience with mental illness also resulted in higher scores across all four domains of service provision, lower levels of stigma (18.28 vs. 20.76, p < 0.05) and more positive attitudes (52.24 vs. 50.53, p < 0.01). Regression analyses demonstrated increased frequency of MTM service delivery and more positive attitudes as significantly predictive across all four models for comfort, confidence, willingness and interest. Increased delivery of pharmacy services was significantly associated with both willingness and interest to provide mental illness-specific services. Conclusion Despite willingness/interest to provide services to patients with mental illness, decreased levels of comfort/confidence remain service-related barriers for community pharmacists.

The Role of Pharmacists in the Opioid Epidemic: An Examination of Pharmacist-Focused Initiatives Across the United States and North Carolina.

A pharmacy presence on national, state, and local levels is helping to address the opioid epidemic. This article will comment on and examine how pharmacists are working together with the health care team and community to address the opioid crisis.

Community pharmacists' attitudes toward providing care and services to patients with severe and persistent mental illness.

OBJECTIVES: To assess community pharmacists' attitudes toward working with patients who have severe and persistent mental illness (SPMI) and to identify perceived barriers to providing care and services to this population. DESIGN: This study was a cross-sectional survey of community pharmacists in North Carolina. The questionnaire, which was distributed electronically, included demographic questions about the responder and pharmacy in which they practiced, Likert-type scale questions assessing pharmacists' comfort and attitudes towards working with patients with SPMI, and barriers preventing provision of care. The survey remained open for 30 days after distribution. Descriptive and inferential statistics were used to analyze survey results. SETTING AND PARTICIPANTS: All community pharmacists actively licensed in North Carolina. MAIN OUTCOME MEASURES: Pharmacists' perceptions toward working with and delivering care to patients with SPMI. RESULTS: Of the 5582 pharmacists who received the survey, 458 completed it. Most respondents had been practicing 0-5 years (22%) or more than 20 years (51%) and the majority estimated that 0%- 25% of their patient population had SPMI. Ninety-one percent agreed that SPMI were real diseases, 81.6% agreed that patients with SPMI often misunderstand information about their medications, and 53.5% disagreed that patients with SPMI can independently manage their medications. Pharmacists responded that they felt confident monitoring efficacy and recognizing adverse effects of medications used to treat SPMI only 28.1% and 48.3% of the time, respectively. The key barriers identified in preventing community pharmacists from providing optimal care and services to this population are lack of time and lack of confidence in managing and monitoring medications used to treat SPMI. CONCLUSION: Although pharmacists had a positive attitude toward working with this population, multiple barriers were identified that prevented optimal care. Identifying solutions to overcome these barriers could help to improve the overall care and increase the likelihood of success in treating patients with SPMI.

Medical mimics: Differential diagnostic considerations for psychiatric symptoms.

Patients with underlying medical disease can present to the health care system with psychiatric symptoms predominating. Identification of an underlying medical condition masquerading as a psychiatric disorder can be challenging for clinicians, especially in patients with an existing psychiatric condition. The term medical mimic or secondary psychosis has been used to describe this clinical situation. Diagnostic categories from The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, that may encompass medical mimics include substance-induced disorders, which includes medications, and unspecified mental disorder due to another medical condition in situations where the clinician may lack needed information for a complete diagnosis. At this time, there is no single diagnostic test or procedure available to differentiate primary versus secondary psychosis on the basis of psychopathology presentation alone. When considering a diagnosis, clinicians should evaluate for the presence of atypical features uncharacteristic of the psychiatric symptoms observed; this may include changes in functionality and/or age of onset and symptom presentation severity. The purpose of this work is to provide a structured clinical framework for evaluation for medical mimics, identify groups considered to be at highest risk for medical mimics, and present common syndromic features suggestive of a medical mimic. Selected case scenarios are used to illustrate key concepts for evaluating and assessing a patient presenting with acute psychiatric symptomatology to improve judgment in ruling out potential medical causality.

Readmission Patterns and Effectiveness of Transitional Care Among Medicaid Patients With Schizophrenia and Medical Comorbidity.

BACKGROUND: Patients with chronic medical and mental health comorbidities are at increased risk of hospital admission, but little is known about their hospital utilization patterns or whether nurse-directed transitional care interventions have any appreciable impact on future hospitalizations. METHOD: Using paid Medicaid claims and a care management database, we examined patterns of hospital utilization for adults with multiple chronic conditions where one of the conditions was schizophrenia. Patients were enrolled in Community Care of North Carolina's medical home program and were discharged from 100 different hospitals throughout the state from July 1, 2010 through June 30, 2011. We examined readmission rates after psychiatric and nonpsychiatric hospital discharges, and we compared patients who received community-based, nurse-directed, transitional care management services to patients who received usual care. RESULTS: A total of 1,717 patients were included in the final analysis. Patients in this study experienced 980 readmissions over the course of 1 year, with 20% of readmissions for a different reason than the primary hospitalization, and 36% of readmissions occurring at a different hospital. Controlling for demographic, clinical, and hospital characteristics, patients receiving transitional care (n = 1,104) were as much as 30% less likely to experience a readmission during the year following discharge compared to patients receiving usual care (n = 613). LIMITATIONS: This descriptive study reports on a nonrandomized intervention and its impact on service utilization for Medicaid patients with complex illnesses in North Carolina. CONCLUSIONS: Regardless of the reason for hospitalization, patients with chronic medical and psychiatric conditions may benefit from transitional care support that addresses both conditions. This holds true even when the patient is already receiving intensive outpatient psychiatric care.

Psychoactive Medication Misadventuring in Correctional Health Care.

Due to multiple factors, unprecedented numbers of individuals with mental health disorders and many with comorbid substance use disorders are now incarcerated in jails and prisons. This article details a variety of medication use and potential abuse/misuse/misadventuring topics that are unique to the correctional health care setting, with emphasis on how the large number of persons with psychiatric and/or substance use disorders affects these issues and methods that correctional systems commonly use to manage these inmate-patients. Also discussed are the potential for inmate feigning or malingering as a goal-directed behavior, potential for misadventuring/abuse of commonly used medications, urine drug screening/surveillance, and the effect of psychoactive medications on heat tolerance and environmental issues.

The chronic pain initiative and community care of North Carolina.

The rate of unintentional deaths from opioid poisoning has reached epidemic proportions. One model of successful intervention is Project Lazarus, an integrated-care pilot program in Wilkes County, North Carolina. Community Care of North Carolina, supported by a grant of $1.3 million from the Kate B. Reynolds Charitable Trust and matching funds of $1.3 million from the North Carolina Office of Rural Health and Community Care, is now expanding the Project Lazarus approach statewide.

A+KIDS, a web-based antipsychotic registry for North Carolina youths: an alternative to prior authorization.

OBJECTIVE: The rise in use of antipsychotics among U.S. children is well documented. Compliance rates with current safety-monitoring guidelines are low. In response, the North Carolina Division of Medical Assistance established the Antipsychotics-Keeping It Documented for Safety (A+KIDS) registry. The initial objectives of the project were to successfully establish a Web-based safety registry and to obtain and evaluate clinical information derived from the registry. METHODS: In April 2011, A+KIDS began asking prescribers of antipsychotics for children age 12 and under to respond to a set of questions regarding dose, indication, and usage history. Antipsychotic registrations were examined by linking North Carolina Medicaid prescription claims to registry entries. Prescribers were classified into different types, and the number of patients and registrations per prescriber were examined. RESULTS: In the initial six months, 730 prescribers registered 5,532 patients, 19% below age seven. By month 6 of the registry, 72% of all fills were registered with the program. Top diagnosis groups for registry patients were unspecified mood disorders, autism spectrum disorders, and disruptive behavior disorders. Top target symptoms were aggression (48%), irritability (19%), and impulsivity (11%). Psychosis accounted for 5% of the target symptoms. Twenty-eight percent of children were receiving no form of psychotherapy. Twenty-five percent of all A+KIDS prescribers were responsible for 81% of the registrations. CONCLUSIONS: The A+KIDS registry initiative has been successful, as measured by rapid uptake, and is providing clinical information not available from claims data alone. Future efforts will allow for detailed examinations of antipsychotic utilization and further safety improvement.

Impact of complete blood count sampling time change on white blood cell and absolute neutrophil count values in clozapine recipients.

INTRODUCTION: Despite its superior efficacy, clozapine is typically reserved for treatment-refractory schizophrenia due to the risk of agranulocytosis with an occurrence of up to 1% in recipients. The FDA has rigid treatment guidelines for hematologic monitoring for clozapine patients. If the white blood cell (WBC) count or absolute neutrophil count (ANC) falls below predetermined values, clozapine treatment must be held or discontinued. Diurnal and ethnic variations in complete blood count (CBC) values, somewhat dependent upon blood sampling time have been reported, and called pseudoneutropenia, which appears independent of clozapine therapy. Unnecessary treatment interruption or discontinuation is costly and may lead to disease relapse. The purpose of this study was to evaluate the effect of a time change in CBC sampling on WBC and ANC values in a group of clozapine patients in a regional public inpatient psychiatric facility. METHODS: Facility CBC sampling for clozapine patients was switched from 0630 to on or after 0830. A retrospective record review was conducted for all patients who were receiving clozapine before and after the time switch, with a minimum of six values pre- and post-change. CBC values sampled on or after 0830 were accepted as applicable post data, as patients are awakened daily at 0630, and a minimum of two hours of wakefulness/mobility had occurred. Patient medical records, automated lab information system, and the Clozapine National Registry were data sources. Data extracted included WBC/ANC values (with date/time of sampling) and demographic information (DOB, sex, weight, height, BMI, and ethnicity). The data were analyzed using repeated measures ANOVA. RESULTS: Ten patients (80% male, 90% Caucasian, mean age=55.7 years) met study criteria. The difference in the pre/post time change WBC values was marginally significant (mean increase=667/mm3, p=.07), with a significant difference (mean increase=1,130/mm3, p=.003) between the pre/post time change ANC values. ANC values were more positively impacted by the sampling time change than WBC values in this sample. The mean sampling time change across all subjects pre/post was 5 hours 24 minutes. CONCLUSIONS: All reasonable steps should be considered to safely continue an effective therapy in treatment-refractory schizophrenia. A larger, more ethnically diverse sample is needed to validate the present work; however, changing the timing of CBC sampling for clozapine patients from early morning to after a minimum two-hour period of wakefulness/movement may have potential to improve WBC and ANC values. Marginal improvements in resultant WBC/ANC values could potentially allow clozapine therapy to continue uninterrupted per FDA monitoring guidelines.

Adjunctive lamotrigine for refractory epilepsy in adolescents with mental retardation.

Epilepsy is a major comorbid condition in adolescents with mental retardation and is often characterized by multiple seizure types that are refractory to treatment. This study (n = 22) describes a subanalysis of data from a larger multicenter study of adjunctive lamotrigine therapy in patients with mental retardation and refractory epilepsy and focuses on the outcome measures of seizure reduction, safety and tolerability, and impact on behaviors in adolescents with mental retardation and refractory epilepsy. The study kept baseline antiepileptic drugs constant and titrated lamotrigine over 8 weeks to the target dose, followed by an 8-week maintenance phase and then a 12-week optimization phase during which all antiepileptic drugs and lamotrigine could be altered as clinically indicated. Sixty percent of subjects had a 50% decrease in seizures by the end of the maintenance phase and a mean 39% reduction in seizure frequency by the end of the maintenance phase (25% by end of study) compared with baseline. Global improvements were observed in most patients, with statistically significant improvements in the Aberrant Behavior Checklist and the Habilitative Improvement Scale, which is predictive of less need for supportive care in activities of daily living and thus enhanced potential for greater independence. Lamotrigine-associated improvements in behavior can be attributed to improved control of seizures, a reduction in concomitant antiepileptic drugs, and/or direct mood-stabilizing and behavior-enhancing properties independent of the antiseizure effects of the drug. The results of this study suggest that lamotrigine is an important treatment option in adolescents with mental retardation and comorbid epilepsy.

Efficacy and tolerability of adjunctive lamotrigine for refractory epilepsy in institutional or community residents with mental retardation.

OBJECTIVE: To determine whether the efficacy and tolerability of adjunctive lamotrigine differ as a function of whether persons with mental retardation and refractory epilepsy resided in institutions or the community. RESEARCH DESIGN AND METHODS: The analysis was retrospective and employed data from a previously published, open-label study. To be eligible for enrollment, patients needed to be receiving stable regimens of up to three antiepileptic medications at enrollment and to have experienced at least two seizures per month in the 3 months prior to enrollment. The study included an Escalation Phase during which lamotrigine was titrated to a target dose, an 8-week Maintenance Phase during which doses of lamotrigine and concomitant antiepileptic drugs were maintained, and a 12-week Optimization Phase during which doses of antiepileptic drugs could be adjusted. Outcomes of interest included baseline characteristics; the percentage of persons with 25%, 50%, and 75% reductions in seizure frequency and with zero seizures; investigator-rated clinical status; and mean scores on the Habilitative Improvement Scale and the Aberrant Behavior Checklist. The small sample size did not allow for sufficient power for statistical comparisons between groups. RESULTS: Demographics and baseline clinical characteristics were similar between groups (31 institutional and 36 community residents) except institutional residents were more likely to have severe or profound mental retardation and complex partial and partial secondarily generalized seizures. The percentages of persons with 25%, 50%, and 75% reductions in seizure frequency and zero seizures were 64%, 50%, 29%, and 18% respectively, for community residents and 42%, 38%, 23%, and 12% for institutional residents. Investigator-rated clinical status at the end of the Maintenance Phase was improved versus baseline in 68% of community residents and 62% of institutional residents. Most individuals (81% of institutionalized persons, 69% of community-dwelling persons) were considered to have experienced no change in adverse events with the addition of lamotrigine. The mean Habilitative Improvement Scale score was significantly improved (p < or = 0.05) versus baseline at the end of the Escalation, Maintenance, and Optimization Phases in both groups. CONCLUSION: The efficacy and tolerability of lamotrigine were similar between institutional residents and community residents despite the numerically higher prevalence of severe or profound mental retardation among institutional residents.

Metabolic effects associated with atypical antipsychotic treatment in the developmentally disabled.

OBJECTIVE: Atypical antipsychotics, especially clozapine and olanzapine, have been increasingly associated with weight gain and other adverse metabolic events (diabetes mellitus, hyperlipidemia) in non-mentally retarded populations. This report explores the incidence of this phenomenon in an institution-dwelling population of individuals with developmental disabilities. METHOD: A retrospective longitudinal analysis was performed for a sample of 41 adults with developmental disabilities and comorbid psychiatric and/or behavioral syndromes for whom treatment was converted from typical antipsychotics to olanzapine or risperidone for a minimum period of 2 years. Data were collected from October 1998 to September 2002. Among parameters analyzed were chlorpromazine equivalent dosage of antipsychotic, metabolic parameters, body mass index (BMI), level of concurrent medications, and concomitant dietary restrictions. RESULTS: Thirty-two study subjects (78.0%) were men. The mean age of the study subjects was 43.6 years (at the end of the study). Thirty-seven (90.2%) had severe-to-profound mental retardation. Eight (19.5%) were on a restricted diet. Twenty-three subjects (56.1%) were switched from a typical antipsychotic to olanzapine, and 18 subjects (43.9%) were switched from a typical antipsychotic to risperidone. Of the subsample of subjects who were switched from a typical antipsychotic to risperidone, 12 (66.7%) went on to be switched to olanzapine because of either emergent side effects or lack of efficacy. For the overall sample (N = 41), there was a 19.3% increase in chlorpromazine-equivalent antipsychotic dosage from baseline to the 2-year endpoint along with a 5.6% decrease in fasting blood glucose from baseline to the 2-year endpoint. There were no significant differences between baseline and endpoint values for BMI, total cholesterol, low-density lipoprotein cholesterol, or triglycerides. CONCLUSION: The findings of this 2-year evaluation suggest that clinically or statistically significant BMI increases as well as blood glucose and lipid elevations are not unavoidably correlated with the use of the atypical antipsychotic agents olanzapine and risperi-done and may be minimized by careful monitoring, a regimen of dietary control, and a moderate activity level in a residential population of individuals with mental retardation.

Impact of new-generation agents on antiepileptic drug prescribing patterns in a residential ICF-MR facility.

OBJECTIVE: Describe the impact of newer antiepileptic drugs (AEDs) on prescribing practices in a large, residential intermediate-care facility for the mentally retarded (ICF-MR), with onsite clinical pharmacist support services, over a 15-year period. DESIGN: All residents at the facility receiving AEDs for management of seizure disorder were included in this retrospective assessment. Number and type of AEDs used per individual were recorded and analyzed over the 15-year interval. Current prescribing practices were evaluated regarding rational polytherapy prescribing trends. SETTING: 400-bed residential ICF-MR for the severe to profoundly mentally retarded. PATIENTS/PARTICIPANTS: All individuals residing at the ICF-MR facility receiving AED therapy for a seizure disorder. Residents were primarily in the severe to profound range of developmental disability, with multiple medical comorbidities. INTERVENTIONS: Clinical pharmacists actively participate in all treatment teams and monthly neurology clinic to promote and encourage rational pharmacotherapy. MAIN OUTCOME MEASURES: Prescribing trends related to AED therapy were followed over a 15-year period. Comparisons were made regarding monotherapy and polytherapy at multiple-year intervals, with specific emphasis on how the newer generation AEDs have affected use of older medications. RESULTS: Overall trend from 1988 suggests more monotherapy and less use of barbiturates. Introduction of a new generation of AEDs has not affected the overall trend toward one- or two-drug regimens over the period in review. CONCLUSION: The relative stability of the number of AEDs per resident during the introduction of a new generation of AEDs suggests that as new drugs are added, ineffective or problem-prone drugs are discontinued.